CLINICAL ETHICS I
Jaromír Matějek, Institut for Ethics, Third
Medical Faculty, Charles University in Prague
CLINICAL ETHICS - INTRODUCTION
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Goal of this course is to help clinicians understand and
manage the cases they encounter in their practices, and on
those occasions when ethical disagreements emerge, to
guide patients, families, clinicians, and ethics committees
toward the resolution of clinical ethical conflicts.
By clinicians we mean not only physicians and surgeons
but also nurses, socialworkers, psychologists, clinical
ethicists, medical technicians, chaplains, and others
responsible for the welfare of patients.
Some of these clinicians will also be members of ethics
committees who deliberate about the ethics policies of their
hospitals and about ethical problems in particular cases.
Our audience also includes families and other persons close
to patients, who may participate in decisions about their
care.
CLINICAL ETHICS - INTRODUCTION
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Ethical issues are imbedded in every clinical
encounter between patients and caregivers because
the care of patients always involves both technical
and moral considerations.
The central feature of this clinical encounter is the
therapeutic relationship between a physician and a
patient, a relationship that is permeated with ethical
responsibilities.
Physicians must aim, in the words of Hippocrates, "to
help and do no harm."
Modern physicians approach the doctor–patient
relationship with a professional identity that includes
the obligations to provide competent care to the
patient, to preserve confidentiality, and to
communicate honestly and compassionately.
CLINICAL ETHICS - INTRODUCTION
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Ethical issues are imbedded in every clinical
encounter between patients and caregivers because
the care of patients always involves both technical
and moral considerations.
The central feature of this clinical encounter is the
therapeutic relationship between a physician and a
patient, a relationship that is permeated with ethical
responsibilities.
Physicians must aim, in the words of Hippocrates, "to
help and do no harm."
Modern physicians approach the doctor–patient
relationship with a professional identity that includes
the obligations to provide competent care to the
patient, to preserve confidentiality, and to
communicate honestly and compassionately.
CLINICAL ETHICS - INTRODUCTION
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In the usual course of a therapeutic relationship,
clinical care and ethical duties run smoothly together.
The reason is that generally the patient and
physician share the same goal: to respond to the
medical problems and needs of the patient.
For example, a patient presents with a distressing
cough and wants relief; a physician responds to the
patient by utilizing the correct means to diagnose and
treat this condition.
In this situation, the treatment for, say, a mild
asthma attack is effective and the patient is satisfied.
At the same time an ethical action has taken place:
the patient is helped and not harmed.
CLINICAL ETHICS - INTRODUCTION
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In other cases, this simple scene becomes complicated. The patient's
asthma may be caused by a cancer obstructing the airway. This
disease may be life-threatening and the treatment may be complex,
difficult and may prove unsuccessful.
On other occasions, the smooth course of the doctor–patient
relationship may be interrupted by what we call an ethical question:
a doubt about the right action when ethical responsibilities conflict or
when their meaning is uncertain or confused.
For example, the physician's duty to cure is countered by a patient's
refusal of indicated treatment, or the patient cannot afford treatment
because of lack of insurance.
The principles that usually bring the clinician and the patient into a
therapeutic relationship seem to collide.
This collision blocks the process of deciding and acting that is
intrinsic to clinical care. This confusion and conflict can become
distressing for all parties. This course , then, aims to elucidate both
the ethical dimensions of care in ordinary clinical activities that are
not controversial, as well as when doubt about right action blocks
decision.
CLINICAL ETHICS - INTRODUCTION
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For example, the physician's duty to cure is countered
by a patient's refusal of indicated treatment, or the
patient cannot afford treatment because of lack of
insurance.
The principles that usually bring the clinician and the
patient into a therapeutic relationship seem to collide.
This collision blocks the process of deciding and
acting that is intrinsic to clinical care. This confusion
and conflict can become distressing for all parties.
This course, then, aims to elucidate both the ethical
dimensions of care in ordinary clinical activities that
are not controversial, as well as when doubt about
right action blocks decisions.
CLINICAL ETHICS - INTRODUCTION
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Clinical ethics, then, is a structured approach to
ethical questions in clinical medicine.
Clinical ethics depends on the larger discipline of
bioethics, which in turn draws upon disciplines such
as moral philosophy, health law, communication
skills, and clinical medicine.
The scholars called "bioethicists" must master this
field. However, clinicians in the daily practice of
medicine can manage with a basic understanding of
certain key ethical issues such as informed consent
and end-of-life care.
Central to the practical application of clinical ethics is
the ability to identify and analyze an ethical question
and to reach a reasonable conclusion and
recommendation for action.
THE FOUR TOPICS
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Bioethics identifies four ethical principles that are
particularly relevant to clinical medicine: the
principles of beneficence, nonmaleficence, respect for
autonomy, and justice. To these, some bioethicists add
empathy, compassion, fidelity, integrity, and other
virtues.
In this book (Albert R. Jonsen, Mark Siegler, William
J. Winslade: Clinical Ethics. A Practical Approach to
Ethical Decisions in Clinical Medicine, 7th edition.
New York : McGraw-Hill Medical, 2010.) the authors
propose four topics that we believe constitute the
essential structure of a case in clinical medicine,
namely, medical indications, patient preferences,
quality of life, and contextual feature
THE FOUR TOPICS
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4.
In this book (Albert R. Jonsen, Mark Siegler,
William J. Winslade: Clinical Ethics. A Practical
Approach to Ethical Decisions in Clinical
Medicine, 7th edition. New York : McGraw-Hill
Medical, 2010.) the authors propose four topics
that we believe constitute the essential structure
of a case in clinical medicine, namely,
medical indications,
patient preferences,
quality of life,
contextual feature
THE FOUR TOPICS
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Sometimes is this approach called „Four Boxes
Approach“.
Every clinical case is a mass of detail that the
clinician must interpret in order to carry out the
reasoning process necessary for diagnosis and
treatment.
Every clinician learns early in training a common
pattern for organizing that mass of detail: chief
complaint, history of the chief complaint, general
medical history of the patient, results of physical
examination, and results of laboratory studies.
The data that are sorted into these patterns lead the
clinician to decisions about diagnosis and treatment.
THE FOUR TOPICS
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This four topics or boxes provide a similar
pattern for collecting, sorting, and ordering the
facts of a clinical ethical problem. Each topic or
"box" is filled with the actual facts of the clinical
case that are relevant to the identification of the
ethical problem, and the contents of all four are
viewed together for a comprehensive picture of
the ethical dimensions of the case.
THE FOUR TOPICS
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Medical indications refer to the diagnostic and
therapeutic interventions that are being used to
evaluate and treat the medical problem in the case.
Patient preferences state the express choices of the
patient about her/his treatment, or the decisions of
those who are authorized to speak for the patient when
the patient is incapable of doing so.
Quality of life describes features of the patient's life
prior to and following treatment, insofar as these
features are pertinent to medical decisions.
Contextual features identify the familial, social,
institutional, financial, and legal settings within
which the particular case takes place, insofar as they
influence medical decisions.
THE FOUR TOPICS
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Clinical ethics is seldom a matter of deciding
between ethical versus unethical, between good
and right versus bad and wrong; rather it
involves finding the better, most reasonable
solutions among the relevant options. While
clinical ethics can sometimes help to rule out
options that are unethical, more frequently,
clinical ethics can clarify a range of permissible
options that patients and clinicians may choose.
Our approach seeks to guide the clinician, and
others involved in the case, toward such
resolutions.
THE FOUR TOPICS
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After all relevant information is gathered into
the Four Boxes, the relationship between that
information and the principles must be assessed.
It sometimes happens that when the data is
collected and properly sorted, an obvious pattern
appears that will identify the ethical problem.
The circumstances of a case often point to one of
the fundamental principles as most important in
the specific case analysis.
THE FOUR TOPICS
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For example, a patient has a critical disease in its
terminal stage, has never expressed preferences
about treatment, has no relatives to speak for him,
and faces great suffering during the time remaining.
This appears at first sight as a case in which the
principles of beneficence and nonmaleficence are
central.
Further, aggressive treatment is no longer likely to be
beneficial; this patient needs palliative care.
At second sight, however, the question becomes a
matter of the principle of respect for autonomy: who is
authorized to make the decision to transition from
intensive to palliative care?
THE FOUR TOPICS
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Ethical reflection moves from this dilemma between
two fundamental principles to an evaluation of how
the circumstances of the case give greater weight to
one or the other of these principles.
For example, after all reasonable attempts to
effectively treat a patient have failed, the continued
application of aggressive measures causes more harm
than good to this patient.
In this light, the principle of nonmaleficence becomes
the most dominant one, and provides an ethical
reason for a decision to provide only palliative care.
The clinician can then formulate a recommendation to
the patient or other decision makers.
This resolution of the case is based on an assessment
of the facts of the case in relation to the ethical
principles relevant to the case.
THE FOUR TOPICS
However, this assessment calls for a further
move: the present case must be compared to
similar cases.
 It is certainly true that in medicine every case is
unique, and every patient "a statistic of one."
 Nevertheless, the case at hand will have
similarities with other cases.
 Other cases may have been thoughtfully
considered—perhaps even adjudicated in the
law—and may provide guidance whereby to
assess the present case.
 Such cases are called paradigm cases.
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THE FOUR TOPICS
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This course is arranged to follow the four-box model.
Each chapter is devoted to one of the four topics. Each
course begins with some general considerations and
ethical principles most relevant to that topic. A series
of questions that exemplify major issues under each
topic are posed. Clinical situations that commonly
generate ethical problems associated with that topic
are stated and illustrated by cases.
A COMMENT that provides a distillation of
prevailing opinion from the bioethical literature
follows.
And concluded with RECOMMENDATIONS that the
formulates from based on extensive experience of
authors of the book.
RESOURCES IN CLINICAL ETHICS
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BIBLIOGRAPHY
American Journal of Bioethics. Taylor and Francis Group
Inc. http://www.bioethics.net.
Beauchamp TL, Childress JF. Principles of Biomedical
Ethics. 6th ed. New York, NY: Oxford University Press;
2009.
Cambridge Quarterly of Healthcare Ethics. 40 West 20th
Street, New York, NY 10011–4211.
http://www.journals.cup.org.
Ford PJ, Dudzinski DM. Complex Ethics Consultations:
Cases that Haunt Us. New York, NY: Cambridge
University Press; 2008
Frankel LR, Goldworth A, Rorty MV, Silverman WA, eds.
Ethical Dilemmas in Pediatrics. New York, NY: Cambridge
University Press; 2005.
Journal of Clinical Ethics. 17100 Cole Road, Hagerstown,
MD 21740. http://www.clinicalethics.com.
RESOURCES IN CLINICAL ETHICS
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Journal of Medical Ethics. BMJ Publishing Group, British
Medical Association, Tavistock Square London WCIH 9JR,
UK. http://www.jme.bmj.com.
Lo B. Resolving Ethical Dilemmas: A Guide for Clinicians. 4th
ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.
Post SG, ed. Encyclopedia of Bioethics. 3rd ed. Farmington
Hills, MI: Gale; 2003.
Singer PA, Viens AM. The Cambridge Textbook of Bioethics.
New York, NY: Cambridge University Press; 2008.
Steinbock B, ed. The Oxford Handbook of Bioethics. New York,
NY: Oxford University Press; 2009.
The Hastings Center Report. The Hastings Center, Garrison,
NY, 10524–5555. E-mail: mail@thehastingscenter.org;
http://www.thehastingscenter.org.
Walters L, Kahn TJ, eds. Bibliography of Bioethics.
Washington, DC: Georgetown University Press. [Published
annually].
RESOURCES IN CLINICAL ETHICS
Web
 www.nlm.nih.gov/bsd/bioethics.html
 http://
bioethics.georgetown.edu/databases/index.htm
 www.nih.gov/sigs/bioethics
 http://virtualmentor.amaassn.org
 www.uptodate.com
 http://depts.washington.edu/bhdept.
 http://www.unesco.org/shs/ethics/geobs
 www.accessmedicine.com
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MEDICAL INDICATIONS
Clinical Ethics: A Practical Approach to Ethical
Decisions in Clinical Medicine
MEDICAL INDICATIONS: INTRODUCTION
This part treats the first topic relevant to any
ethical problem in clinical medicine, namely, the
indications for or against medical intervention.
 In most cases, treatment decisions that are based
on medical indications are straightforward and
present no obvious ethical problems.
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MEDICAL INDICATIONS: INTRODUCTION
Example
 A patient complains of frequent urination
accompanied by a burning sensation.
 The physician suspects a urinary tract infection,
obtains a confirmatory culture, and prescribes an
antibiotic.
 The physician explains to the patient the nature
of the condition and the reason for prescribing
the medication.
 The patient obtains the prescription, takes the
medication, and is cured of the infection.
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MEDICAL INDICATIONS: INTRODUCTION
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This is a case of clinical ethics, not because it shows
an ethical problem, but because it demonstrates how
the principles commonly considered necessary for
ethical medical care, namely, respect for autonomy,
beneficence, nonmaleficence, and justice, are satisfied
in the clinical circumstances of this case.
Medical indications are sufficiently clear so that the
physician can make a diagnosis and prescribe an
effective therapy to benefit the patient.
The patient's preferences coincide with the
physician's recommendations. The patient's quality of
life, presently made unpleasant by the infection, is
improved. This case occurs in a context in which
medications are available, insurance pays the bill,
and no problems with family or institution are
present.
MEDICAL INDICATIONS: INTRODUCTION
BUT this case, which raises no ethical concerns,
would present an ethical problem if the patient
stated that he did not believe in antibiotics, or if
the urinary tract infection developed in the last
days of a terminal illness, or if the infection was
associated with a sexually transmitted disease in
which sexual partners might be endangered, or if
the patient could not pay for the care.
 Sometimes, these problems can be readily
resolved; at other times, they can become major
obstacles in the management of the case.
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MEDICAL INDICATIONS: INTRODUCTION
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In this part, we first define medical indications and explain
the ethical principles most relevant to medical indications,
namely, beneficence and nonmaleficence. We discuss the
relationship of these principles to medical professionalism.
We then pose a series of questions that link medical
indications to these principles. In discussing these
questions, we treat important features of clinical medicine
related to medical indications, including the goals and
benefits of medicine, clinical judgment and uncertainty,
evidence-based medicine, and medical error.
We offer typical cases to illustrate these discussions. We
then consider three ethical issues in which medical
indications are particularly prominent: (1) nonbeneficial (or
futile) treatment, (2) cardiopulmonary resuscitation (CPR)
and do-not-resuscitate (DNR) orders, and (3) the
determination of death.
DEFINITION OF MEDICAL INDICATIONS
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Medical Indications are the facts, opinions, and
interpretations about the patient's physical and/or
psychological condition that provide a reasonable
basis for diagnostic and therapeutic activities aiming
to realize the overall goals of medicine: prevention,
cure, and care of illness and injury.
Every discussion of an ethical problem in clinical
medicine should begin with a statement of medical
indications. In the usual clinical presentation, this
review of indications for medical intervention leads to
the determination of goals and the formulation of
recommendations to the patient.
Therefore, medical indications are those facts about
the patient's physiological or psychological condition
that indicate which forms of diagnostic, therapeutic,
or educational interventions are appropriate.
THE ETHICAL PRINCIPLES OF
BENEFICENCE AND NONMALEFICENCE
Medical Indications describe the day-to-day work
of clinical care for patients—diagnosing their
condition and providing helpful treatments. The
ethical principles that should govern these
activities are the principles of beneficence and
nonmaleficence, that is, acting so as to benefit
the patients and not harm them.
 The most ancient moral maxim of medicine,
stated in the Hippocratic oath, is "I will use
treatment to benefit the sick according to my
ability and judgment but never with a view to
injury and wrongdoing." Another Hippocratic
imperative to physicians states, "be of benefit and
do no harm" (Epidemics I).
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THE ETHICAL PRINCIPLES OF
BENEFICENCE AND NONMALEFICENCE
There are many ways to benefit persons, for
example, by educating, hiring, and promoting an
employee; giving a recommendation; and making
a gift. T
 here are also many ways to harm, for example, by
slandering, stealing, and beating.
 In medicine, benefit and harm have a
specific meaning: helping by trying to heal
and doing so as safely and painlessly as
possible.
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THE ETHICAL PRINCIPLES OF
BENEFICENCE AND NONMALEFICENCE
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Therefore, in medical ethics,
beneficence primarily means the duty to try to bring about
those improvements in physical or psychological health that
medicine can achieve.
These objective effects of diagnostic and therapeutic actions
are, for example, diagnosing and curing an infection,
treating cancer that leads to remission, and facilitating the
healing of a fracture.
Nonmaleficence means going about these activities in ways
that prevent further injury or reduce its risk. So, this topic
will treat medical benefits as objective contributions to the
health of a patient. The subjective aspects of patients'
choices, that is, their estimate of the value and utility that
medical contributions bring to them personally and their
acceptance and rejection of them, are discussed under part
two, "Patient Preferences," and part three "Quality of Life."
BENEFIT–RISK RATIO
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In medicine, beneficence and nonmaleficence are assessed
in what is called "Benefit–Risk Ratio" reasoning.
It would be clearly wrong for a physician to set out to harm
a patient, but it is almost inevitable that when a physician
attempts to benefit a patient, by medication or surgery, for
example, some harm or risk of harm is possible or may
ensue.
Every surgical procedure causes a wound; most drugs have
adverse effects.
Therefore, the principles of beneficence and nonmaleficence
do not merely instruct the clinician to help and do no harm;
they coalesce to guide the clinician's assessment of how
much risk is justified by the intended benefit.
A physician must calculate this "ratio" and fashion it into a
recommendation to the patient who will, in the last
analysis, evaluate it in light of his or her own values.
BENEFIT–RISK RATIO
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Examples. (1) A patient with asthma and
diabetes needs a course of steroids for worsening
asthma, but the doctor knows that steroids will
make diabetes control more difficult. (2) A
surgeon takes a beta-blocking drug to decrease
tremor before operating, but the use of the betablocker exacerbates his asthma.
THE THERAPEUTIC RELATIONSHIP AND
PROFESSIONALISM
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The competence of a physician to benefit the
patient by his or her medical knowledge and
skill, as well as the expectation and desire of the
patient to be benefited by these skills, is a key
moral aspect of a therapeutic relationship. The
principles of beneficence and nonmaleficence are
the central ethical aspects of this relationship.
This therapeutic relationship has further
implications for physicians as professionals.
THE THERAPEUTIC RELATIONSHIP AND
PROFESSIONALISM
As the Charter on Medical Professionalism
states, professionalism "demands placing the
interest of patients above those of the physician,
setting and maintaining standards of competence
and integrity, and providing expert advice to
society on matters of health." Professionalism
encourages placing care for the patient ahead of
the business of medicine.
 This implies that physicians should primarily
pursue the goals of medicine in their dealings
with patients, rather than favoring personal,
private goals.
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THE THERAPEUTIC RELATIONSHIP AND
PROFESSIONALISM
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More directly, physicians must avoid exploitation of
patients for their own profit or reputation.
The benefits of medicine are optimal when physicians
and other health professionals demonstrate a
professionalism that includes honesty and integrity,
respect for patients, a commitment to patients'
welfare, a compassionate regard for patients, and a
dedication to maintain competency in knowledge and
technical skills.
In manifesting these virtues, professionalism and
ethics are linked.
The ethical and professional responsibilities of
physicians are closely tied to their ability to fulfill the
goals of medicine in conjunction with their respect for
patients' preferences about the goals of their lives.
A CLINICAL APPROACH TO BENEFICENCE
AND NONMALEFICENCE
The general principles of beneficience and
nonmaleficence must be situated in the clinical
circumstances of the patient. In order to do this,
we propose that clinicians first consider the topic
of Medical Indications.
 We ask five questions that define the scope of the
topic of Medical Indications. These questions
form the structure of this course.
 In answering them, we will explain how the
clinical circumstances are linked to the principles
of beneficence and nonmaleficence.
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A CLINICAL APPROACH TO BENEFICENCE
AND NONMALEFICENCE
1. What is the patient’s medical problém? Is the
problém acute? Chronic? Critical? Reversible?
Emergent? Terminal?
 2. What are the goals of treatment?
 3. In what circumstances are medical treatments
not indicated?
 4. What are the probabilities of success of various
treatment options?
 5. In sum, how cant his patient be benefited by
medical and nursing care, and how can harm be
avoided
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QUESTION ONE—WHAT IS THE PATIENT'S MEDICAL
PROBLEM? IS THE PROBLEM ACUTE? CHRONIC?
CRITICAL? REVERSIBLE? EMERGENT? TERMINAL?
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Clinical medicine is not abstract; it deals with
particular patients who present with particular
health problems.
Therefore, clinical ethics must begin with as clear and
detailed a picture as possible of those problems.
This picture is usually obtained through the standard
methods of clinical medicine—history, physical
diagnosis, data from laboratory studies—interpreted
against a background of clinical experience.
This leads to a differential diagnosis, as well as a
management plan for further diagnostic tests and for
treatment.
As clinicians synthesize and organize the patient's
case, they consider the issues discussed below in
Question 2.
QUESTION ONE—WHAT IS THE PATIENT'S MEDICAL
PROBLEM? IS THE PROBLEM ACUTE? CHRONIC?
CRITICAL? REVERSIBLE? EMERGENT? TERMINAL?
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Important Distinctions: Is the Problem Acute? Chronic?
Critical? Reversible? Emergent? Terminal?
Any differential diagnosis or treatment option will
implicitly answer these questions.
However, it is important to raise them explicitly at the time
of an ethics discussion or consultation.
The ethical implications of particular choices are often
significantly influenced by the answer to these questions.
Persons involved in an ethics discussion, such as the family
of a patient or an ethics committee member, may not be
fully aware of these important features.
It is necessary to be clear about whether the ethical
problem pertains to an acute reversible condition of a
patient who has a terminal disease (such as pneumonia in
a patient with widely metastatic cancer) or to an acute
episode of a chronic condition (such as ketoacidosis in a
diabetic patient).
QUESTION ONE—WHAT IS THE PATIENT'S MEDICAL
PROBLEM? IS THE PROBLEM ACUTE? CHRONIC?
CRITICAL? REVERSIBLE? EMERGENT? TERMINAL?
Therefore, the following points must be clear to
all participants in an ethics discussion:
 A) The disease: A disease may be acute (rapid
onset and short course) or chronic (persistent and
progressive). It can be an emergency (causing
immediate disability unless treated) or a
nonemergency (slowly progressive). Finally, a
disease can be curable (the primary cause is
known and treatable by definitive therapy) or
incurable.
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QUESTION ONE—WHAT IS THE PATIENT'S MEDICAL
PROBLEM? IS THE PROBLEM ACUTE? CHRONIC?
CRITICAL? REVERSIBLE? EMERGENT? TERMINAL?
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The treatment: Proposed treatments depend on
the particular disease being treated. Patients'
decisions about treatment will vary on the basis
of their goals, desires, and values. A medical
intervention may be burdensome (known to cause
serious adverse effects) or nonburdensome
(unlikely to have serious side effects). The
potential burdens of an intervention are
considered by patients and physicians when
deciding on a treatment plan.
QUESTION ONE—WHAT IS THE PATIENT'S MEDICAL
PROBLEM? IS THE PROBLEM ACUTE? CHRONIC?
CRITICAL? REVERSIBLE? EMERGENT? TERMINAL?
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In addition, interventions may be curative (offering
definitive correction of a condition) or supportive
(offering relief of symptoms and slowing the
progression of diseases that are currently incurable).
For certain progressive diseases such as diabetes,
supportive intervention, such as tight glycemic
control, can be very efficacious, stopping or reversing
disease progression and allowing the patient to
maintain a high quality of life for many years.
For other conditions, such as amyotrophic lateral
sclerosis (Lou Gehrig disease) or Alzheimer disease,
interventions and treatments rarely delay the
progression of disease but may palliate symptoms and
successfully treat acute episodes.
FOUR TYPICAL CASES
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Here are offered four typical patients who will
reappear throughout this book as our major
examples. The patients in these cases are given
the names Mr. Cure, Ms. Cope, Mr. Care, Mr.
Comfort.
FOUR TYPICAL CASES
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These pseudonyms are chosen to suggest prominent
features of their medical condition.
Mr. Cure suffers from bacterial meningitis, a serious
but curable acute condition.
Ms. Cope has a chronic condition, insulin-dependent
diabetes that requires not only continual medical
treatment but also the patient's active involvement in
her own care.
Mr. Care has multiple sclerosis (MS), a disease that
cannot currently be cured but whose inexorable
deterioration can sometimes be delayed by treatments
and always can be alleviated by good medical care.
Ms. Comfort has breast cancer that has metastasized,
for which there is a low probability of cure even under
a regimen of intensive intervention.
MR. CURE
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Case I
Mr. Cure, a 24-year-old graduate student, has been
brought to the emergency room (ER) by a friend.
Previously in good health, he is complaining of a
severe headache and stiff neck.
Physical examination shows a somnolent patient
without focal neurologic signs but with a temperature
of 39.5°C and nuchal rigidity.
An examination of spinal fluid reveals cloudy fluid
with a white blood cell count of 2000; a Gram stain of
the fluid shows many gram-positive diplococci.
A diagnosis of bacterial meningitis is made;
administration of antibiotics is recommended.
MR. CURE
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Comment
In this case, the medical indications are the clinical data
that suggest a diagnosis of bacterial meningitis for which a
specific therapy, namely, administration of antibiotics, is
appropriate.
Nothing yet suggests that this case poses any ethical
problem. However, in Chapter Two, we shall see how
ethical problems emerge from what appears to be a
noncontroversial clinical situation: Mr. Cure will refuse
therapy.
That refusal will cause consternation among the physicians
and the nurses caring for him; it will also raise an ethical
conflict between the duty of physicians to benefit the
patient versus the autonomy of the patient.
When that problem appears, clinicians may be tempted to
leap directly to the ethical problems of the patient's refusal.
MR. CURE
We suggest that the first step in ethical analysis
not be such a leap but rather a clear exposition of
the medical indications.
 Analysis should begin with answers to the
questions,
 "What is the diagnosis?"
 "What are the medical indications for
treatment?"
 "What are the probabilities of success?"
 "What are the consequences of failure to treat?"
 "Are there any reasonable alternatives for
treating this clinical problem?"

MS. COPE





Case II
Ms. Cope is a 42-year-old woman whose insulindependent diabetes was diagnosed at age 18.
Despite good compliance with an insulin and dietary
regimen, she experienced frequent episodes of
ketoacidosis and hypoglycemia, which necessitated
repeated hospitalizations and ER care.
For the last few years, her diabetes has been
controlled with an implanted insulin pump. Twentyfour years after the onset of diabetes, she has no
functional impairment from her disease.
However, fundoscopic examination reveals a
moderate number of microaneurysms, and urinalysis
shows increased microalbuminuria
MR. CARE
Case III
 Mr. Care, a 44-year-old man, was diagnosed with
MS 15 years ago.
 For the past 12 years, he has experienced
progressive deterioration and has not responded
to the medications currently approved to delay
MS progression.
 He is now confined to a wheelchair and for 2
years has required an indwelling Foley catheter
because of an atonic bladder.
 In the last year, he has become profoundly
depressed, is uncommunicative even with close
family, and rarely rises from bed.

MS. COMFORT
Case IV
 Ms. Comfort is a 58-year-old woman with
metastatic breast cancer. Three years ago, she
underwent a mastectomy with reconstruction.
Dissected nodes revealed infiltrative disease. She
received several courses of chemotherapy and
radiation.

FOUR TYPICAL CASES







Comment
In these four cases, we present a very simplified picture of
patients seen in terms of medical indications, that is,
diagnosis and treatment.
No particular ethical problems are described.
As the course advances, various problems will arise that merit
the name clinical ethical problems. Some of these are related
to changes in medical indications themselves, whereas some
are due to the patients' preferences, their quality of life, and
the context of care.
Part Two, Three, and Four treat these questions. Mr. Cure,
Ms. Cope, Mr. Care, and Ms. Comfort will appear more
frequently.
Details of these cases will occasionally be changed to illustrate
various points as the text proceeds.
In addition to these four model cases, many other case
examples will appear in which the patients will be designated
by initials.
FOUR TYPICAL CASES




The first question of first part of the course, which
examines the patient's immediate presenting
problems, as well as the patient's overall clinical
condition, is centrally important in developing both a
clinical and an ethical analysis of the situation.
This information is the sort usually found in the
patient's chart.
We emphasize that any clinical assessment or any
ethics consultation must begin with a complete review
of this information.
We also emphasize that in some cases, an ethics
consultation by a clinically knowledgeable ethicist
might reveal that some important information is
missing and that clinicians should be encouraged to
obtain it to make the ethical analysis more relevant
and helpful.
QUESTION TWO—WHAT ARE THE GOALS
OF TREATMENT?

In order to understand the ethical issues in a
case, it is necessary to consider the clinical
situation of the patient, that is, the nature of the
disease, the treatment proposed, and the goals of
intervention. The analysis and resolution of an
ethical issue often depend on a clear perception of
these factors.
QUESTION TWO—WHAT ARE THE GOALS
OF TREATMENT?

1.
2.
3.
4.
5.
6.
7.
8.
The general goals of medicine are as follows:
Cure of disease.
Maintenance or improvement of quality of life
through relief of symptoms, pain, and suffering.
Promotion of health and prevention of disease.
Prevention of untimely death.
Improvement of functional status or maintenance of
compromised status.
Education and counseling of patients regarding
their condition and prognosis.
Avoidance of harm to the patient in the course of
care.
Providing relief and support near time of death.
QUESTION TWO—WHAT ARE THE GOALS
OF TREATMENT?





In many cases, most of the general goals of medicine
can be achieved simultaneously.
However, at times, goals will conflict.
For example, when considering the use of
antihypertensive drugs, the goal of reducing the risk
of heart attack and stroke may conflict with the goal
of avoiding harmful side effects, such as impotence
and fatigue, that will impair a patient's quality of life.
In other cases, goals such as curing disease may be
impossible to achieve because of a patient's advanced
condition and/or limitations in scientific and medical
knowledge.
In every medical case, the goals must be clear and
conflicts between goals must be understood and
managed, as much as possible.
QUESTION TWO—WHAT ARE THE GOALS
OF TREATMENT?



An ethical problem may appear in a case if the goals
of intervention are poorly defined, are unclear or
confused, or are overtaken by the rapid course of
disease—goals that are perfectly reasonable when a
patient is admitted for surgery may no longer be
reasonable when, postoperatively, the patient
becomes septic.
Sometimes the ethical problem merely reflects a
failure to clarify for all participants the feasible goals
that the physician has identified; at other times, there
may be a genuine conflict between goals.
Clinical ethics consultation may assist clinicians to
clarify when cure is possible, how long intensive
medical interventions should be continued, and when
comfort should become the primary mode of care.
QUESTION THREE: IN WHAT CIRCUMSTANCES
ARE MEDICAL TREATMENTS NOT INDICATED?




One of the major sources of ethical problems is the
determination whether a particular intervention is, or is
not, indicated. Innumerable interventions are available to
modern medicine, from counseling to drugs to surgery.
In any particular clinical case, only some of these available
interventions are indicated, that is, only some
interventions are clearly related to the needs and data of
the clinical situation and to the goals of medicine.
The competent clinician always judges what intervention is
indicated for the case at hand.
Therefore, the term "medically indicated" describes
what a sound clinical judgment determines to be
physiologically and medically appropriate in the
circumstances of a particular case.
QUESTION THREE: IN WHAT CIRCUMSTANCES
ARE MEDICAL TREATMENTS NOT INDICATED?




Interventions are indicated, then, when the patient's
physical or mental condition may be improved by
their application. Interventions may be nonindicated
for a variety of reasons.
First, the intervention may have no scientifically
demonstrated effect on the disease to be treated and
yet be erroneously selected by the clinician or desired
by the patient.
Second, an intervention known to be efficacious in
general may not have the usual effect in some
patients because of individual differences in
constitution or in the disease.
Third, an intervention appropriate at one time in the
patient's course may cease to be appropriate at a later
time.
QUESTION THREE: IN WHAT CIRCUMSTANCES
ARE MEDICAL TREATMENTS NOT INDICATED?






Case
Mr. Care, a 44-year-old married man with two adult children,
was diagnosed as having MS (Multiple Sclerosis) 15 years ago.
During the past 12 years, the patient has experienced
progressive deterioration and has not responded to the drugs
currently approved to delay progression of MS.
He is now confined to a wheelchair and for the last 2 years has
required an indwelling Foley catheter because of an atonic
bladder.
He is now blind in one eye, with markedly decreased vision in
the other. He has been hospitalized several times because of
pyelonephritis and urosepsis. In the course of the last year, he
has become profoundly depressed, is uncommunicative even
with close family, and refuses to leave his bed.
During the entire course of his illness, he has refused to
discuss the issue of terminal care, saying he found such
discussion depressing and discouraging.
THE DYING PATIENT





Decisions about what treatment is indicated for Mr.
Care are influenced by whether he is viewed as a
"dying" patient, a terminally ill patient, or as an
incurable patient.
Many interventions become nonindicated when the
patient is about to die. In this section, we use the
word dying to describe a situation when clinical
conditions indicate definitively that the patient's
organ systems are disintegrating rapidly and
irreversibly.
Death can be expected within hours.
This condition is sometimes described as "actively
dying" or "imminently dying."
In this situation, indications for medical intervention
change significantly.
THE DYING PATIENT








Mr. Care, in the advanced stages of MS, suffers from deep
decubitus ulcers and osteomyelitis, neither of which has
responded to treatment efforts, including skin grafts.
During the past month, the patient has been admitted three
times to the intensive care unit (ICU) with aspiration
pneumonia and has required mechanical ventilation.
He is admitted again, requiring ventilation and, after 4 days,
becomes septic.
On the next day, he is noted to have increasingly stiff lungs
and poor oxygenation.
In several hours, his blood pressure is 60/40 mm Hg and
decreasing.
He is unresponsive to pressors and volume expanders.
His arterial oxygen saturation is 45%.
He is anuric, his creatinine is 5.5 mg/dL and rising, and his
arterial pH is 6.92. A house officer asks whether ventilation
and pressors are futile and should be discontinued.
THE DYING PATIENT




Comment
Mr. Care has multisystem organ failure and is dying.
Medical intervention at this point is sometimes called
futile, that is, offering no therapeutic benefit to the patient.
Judgments about futility are often very controversial and
its meaning will be fully discussed below in Medical
Futility.
At this point in Mr. Care's case, the house officer uses the
word futile in a quite obvious, noncontroversial way: as a
shorthand description of a condition in which physiological
systems have deteriorated so drastically that no known
medical intervention can reverse the decline.
The judgment of futility in this case approaches certainty.
Some commentators use the phrase physiological futility
for this situation, and some believe that it is the only
situation in which the word futility should be applied.
THE DYING PATIENT
Recommendation
 Mr. Care is dying. His death will take place
within hours. Ventilation and vasopressors are
no longer indicated, because they are now having
no positive physiological effect. Physiologic
futility is an ethical justification for the physician
to recommend withdrawing all interventions,
with the exception of those that may provide
comfort. If the patient's family requests
continued interventions, see the discussion in
Medical Utility.

THE TERMINALLY ILL PATIENT
Judgments about whether certain interventions
are indicated must be reevaluated when a patient
is in a terminal condition. There is no standard
clinical definition of terminal.
 The word is often loosely used to refer to the
prognosis of any patient with a lethal disease.
 In the Medicare and Medicaid eligibility rules for
reimbursement of hospice care, terminal is
defined as a prediction having 6 months or less to
live. This is an administrative rather than a
clinical definition.

THE TERMINALLY ILL PATIENT






In clinical medicine, terminal should be applied only to
those patients whom experienced clinicians expect will die
from a lethal, progressive disease, despite appropriate
treatment, in a relatively short period, measured in days,
weeks, or several months at most.
Diagnosis of a terminal condition should be based on
medical evidence and clinical judgment that the condition
is progressive, irreversible, and lethal.
The benefits of accurate prognostication include informing
patients and families about the situation, allowing them to
plan their remaining time and arrange appropriate forms
of care.
However, such prognostication must be made with great
caution.
More than a few studies have shown that even experienced
clinicians often fail to make accurate prognoses.
Some physicians are overly pessimistic, but one major
study shows that even more
THE TERMINALLY ILL PATIENT
Case
 Prior to the hospitalization described above, Mr.
Care is living at home.
 He requires assistance in all activities of daily
life and is confined to bed.
 He has become confused and disoriented.
 He begins to experience breathing difficulties and
is brought to the emergency department.
 He is now unresponsive and has a high fever and
labored, shallow respirations.

THE TERMINALLY ILL PATIENT






A chest radiograph reveals diffuse haziness
suggestive of adult respiratory distress syndrome;
arterial blood gases show a PO2 of 35, PCO2 of 85, and
pH of 7.02.
Cardiac studies demonstrate an acute anteroseptal
myocardial infarction.
Neurologic and pulmonary consultants agree that he
has primary neuromuscular respiratory insufficiency.
Mr Care's family calls his personal physician, who
immediately consults with the emergency physicians.
Should Mr. Care be intubated and admitted to the
ICU?
Should his acute myocardial infarction be treated
with emergency angioplasty and stenting, or are
these procedures not indicated in this patient's
condition?
THE TERMINALLY ILL PATIENT




Comment
This acute episode is a life-threatening event superimposed
upon a chronic, lethal, and deteriorating condition.
Various interventions might delay Mr. Care's demise.
A respirator may improve gas exchange and support
perfusion of organ systems; fibrinolytic therapy or
angioplasty plus stenting might limit the evolving infarct.
These interventions aim at two of the goals of medicine:
support of compromised function and prolongation of life.
Given the presence of progressive and irreversible disease
in its final stages and radical damage to multiple organ
systems, none of the other important goals can be achieved.
The patient will certainly never be restored to health, and
compromised functions will not be restored but sustained
temporarily by mechanical means.
THE TERMINALLY ILL PATIENT
The following reflections are relevant:
 A) Mr. Care, now unresponsive, has declined to
express preferences about the course of his care,
and nothing is known from other sources about
his preferences.
 Therefore, personal preferences, usually so
important in these decisions, are not available to
clinicians or to surrogates.
 Objective data about survival and sound clinical
discretion about the probabilities of improvement
are the most important factors in formulating a
recommendation to forgo further treatment.

THE TERMINALLY ILL PATIENT
B) Objective information that provides prognostic
criteria may be useful in determining whether a
particular type of intervention will be efficacious.
 Such objective information may include the
patient's diagnosis, physiologic condition,
functional status, nutritional status, and
comorbidities, together with the patient's
estimated likelihood of recovery.
.

THE TERMINALLY ILL PATIENT



One approach to developing these data for patients
admitted to the ICU is the Acute Physiology and
Chronic Health Evaluation (APACHE). This system
combines an acute physiologic score, the Glasgow
Coma Score, age, and a chronic disease score to
estimate a patient's risk of dying during an ICU
admission.
Another new and simpler system, Modified Organ
Dysfunction Score (MODS), records how many organ
systems are dysfunctional and for how many days.
Analyses such as these, done for this patient with
pneumonia, ARDS, and acute MI, would show that
the probability of his surviving this ICU admission is
extremely low. Even though probability is not
equivalent to certainty, in this instance, as
everywhere else in medicine, it is a sound basis for
clinical judgment
THE TERMINALLY ILL PATIENT
C) In these clinical circumstances, the principle
of beneficence, in its sense of helping to remedy
the conditions that are leading to death, is no
longer applicable.
 In the absence of patient preferences, quality of
life and appropriate use of resources become
appropriate ethical considerations.

THE TERMINALLY ILL PATIENT
D) A medical judgment that none of the goals of
medicine can be achieved apart from sustaining
organ function provides the first ethical ground
to conclude that further life-sustaining treatment
can be omitted.
 The physician should formulate a
recommendation to this effect.
 In addition to this ethical grounding, consent of
the patient or the patient's designated surrogate
must be sought

THE INCURABLE PATIENTS WITH
PROGRESSIVE, LETHAL DISEASE




Certain diseases follow a course of gradual and
sometimes occult destruction of the body's physiologic
processes.
Patients who suffer such diseases may experience
their effects continually or intermittently, and with
varying severity.
Eventually, the disease itself or some associated
disorder will cause death. Mr. Care illustrates the
features of this condition.
Multiple sclerosis cannot be cured. Progressive
neurologic complications that include spasticity, loss
of mobility, neurogenic bladder, respiratory
insufficiency, and occasionally dementia are also
irreversible. Still, some interventions, such as
treatment of infection, can relieve symptoms,
maintain some level of function, and prolong life
THE INCURABLE PATIENTS WITH
PROGRESSIVE, LETHAL DISEASE






Case
For the first decade after his diagnosis with MS, Mr.
Care maintained high spirits.
Although he did not like to discuss his disease or its
prognosis, he seemed to understand the progressive
and lethal nature of his condition.
However, in the last few years, he has begun to speak
frequently of "getting this over" and has become
deeply depressed.
He has accepted several trials of antidepressant
medications, but these did not improve his mental
condition.
As serious urinary tract and respiratory infections
became more frequent, he grudgingly submitted to
treatment.
THE INCURABLE PATIENTS WITH
PROGRESSIVE, LETHAL DISEASE
Comment
 Patients in this condition are not terminal, even
though the disease from which they suffer is
incurable.
 However, they may from time to time experience
acute, critical episodes, which, if not treated, will
lead to their death.
 When successfully treated, patients will be
restored to their "baseline condition." In a sense,
they are, at each episode, "potentially terminal."

THE INCURABLE PATIENTS WITH
PROGRESSIVE, LETHAL DISEASE
It may occur to such patients and to their
physicians that these critical episodes offer an
opportunity to end their progressive decline.
 Recall the old medical maxim, "Pneumonia is the
old person's friend." In such a situation, the
issues require a careful review of medical
indications, because the patient's prognosis, with
or without treatment, must be clearly
understood.
 However, the more important questions concern
patient preferences and quality of life.

QUESTION FOUR—WHAT ARE THE
PROBABILITIES OF SUCCESS OF VARIOUS
TREATMENT OPTIONS?



In the above cases, judgments about diagnosis and
treatment reflect a certain level of certainty or
uncertainty. Given the nature of medical science and
the particularities of each patient, clinical judgment
is never absolutely certain.
Clinical medicine was described by Dr. William Osler
as "a science of uncertainty and an art of probability."
The central task of clinicians is to reduce uncertainty
to the extent possible by using clinical data, medical
science, and reasoning to reach a diagnosis and
propose a plan of care. The process by which a
clinician attempts to make consistently good decisions
in the face of uncertainty is called clinical judgment.
QUESTION FOUR—WHAT ARE THE
PROBABILITIES OF SUCCESS OF VARIOUS
TREATMENT OPTIONS?
The inevitable uncertainty of clinical judgment
can be reduced by the methods of evidence-based
medicine, using data from controlled clinical
trials, and by the development of practice
guidelines, which assist the physician's reasoning
through a clinical problem.
 Although evidence-based medicine and practice
guidelines aim to reduce the "uncertainty" and
the "probability" of which Osler spoke, some
degree of uncertainty always remains, because
these methods reach general statistical
conclusions that may not fit the real patient who
is before the physician.

QUESTION FOUR—WHAT ARE THE
PROBABILITIES OF SUCCESS OF VARIOUS
TREATMENT OPTIONS?
In addition to uncertainty about data and their
interpretation, there will be uncertainty about
what action to take in any particular case.
 This is reflected in such questions as "Now that
we have medical evidence about what is possible,
what should we do?"
 "Given all the possibilities, what goals are
appropriate for this patient?"

QUESTION FOUR—WHAT ARE THE
PROBABILITIES OF SUCCESS OF VARIOUS
TREATMENT OPTIONS?




These questions cannot be solely answered by clinical
data.
The ethical principles of beneficence and
nonmaleficence reduce the scope of this sort of
uncertainty by directing intention and effort away
from the wide range of possible diagnoses and
treatments and toward the more narrow range most
likely to help this patient in these circumstances.
However, the ethical principles do not dictate
particular clinical decisions.
These decisions must be confronted in candid,
realistic discussions among clinicians, the patient,
and the family. This is the shared decision making
that constitutes an appropriate professional
relationship.
MEDICAL FUTILITY





An important ethical problem is closely associated
with the probabilistic nature of medical judgment.
The question is whether a high probability that a
particular treatment will be unsuccessful justifies
withholding or withdrawing that treatment.
This is often called the futility problem, or "medically
ineffective or nonbeneficial treatment."
A long, hotly contested debate over "futility" has been
inconclusive.
One definition at the center of the debate states:
"futility designates an effort to provide a benefit to a
patient, which reason and experience suggest is
highly likely to fail and whose rare exceptions cannot
be systematically produced."
MEDICAL FUTILITY
In the The Dying Patient, we have seen the term
"physiologic futility," that is, an utter
impossibility that the desired physiologic
response can be affected by any intervention.
 However, futility more properly is a judgment
about probabilities, and its accuracy depends on
empirical data drawn from clinical studies and
from clinical experience.

MEDICAL FUTILITY
Because clinical studies that demonstrate this
sort of futility are rare, and because clinical
experience is so varied, clinicians make widely
different estimates of futility: physicians'
judgments that various procedures should be
called futile range from 0% to 50% chance of
success, clustering about 10%. Some ethicists and
clinicians deny the utility of the concept of futility
because of its confused meaning and frequently
inappropriate application.
 Others, including ourselves, consider it a useful
term when applied thoughtfully to treatment
decisions about interventions with low likelihood
of success.

MEDICAL FUTILITY
Three main questions about futility are debated:
 (1) What level of statistical or experiential
evidence is required to support a judgment of
futility?
 (2) Who decides whether an intervention is futile,
physicians or patients?
 (3) What process should be used to resolve
disagreements between patients (or their
surrogates) and the medical team about whether
a particular treatment is futile?

MEDICAL FUTILITY





(1) Statistical probability. Clinical futility requires a
probabilistic judgment that an intervention is highly
unlikely to produce the desired result.
This judgment comes from general clinical experience and
from clinical studies that demonstrate low rates of success
for particular interventions, such as CPR for certain types
of patients, or continued ventilatory support for patients
with adult respiratory disease syndrome.
Even the data that are available may prove deceptive in a
particular case because studies apply to groups rather than
individuals.
Further, a lack of agreement exists about how low a level of
probability would justify calling a treatment futile.
One group has suggested that if soundly designed clinical
studies reveal less than a 1% chance of success,
intervention should be considered futile.
MEDICAL FUTILITY



(2) Who decides? It is relatively rare that carefully
designed clinical studies such as the previous reports
provide hard data for determination of futility.
Inevitable debates will ensue about the level of
probability that should represent futility.
Who has the authority to establish the goals of the
intervention and to decide the level of probability for
attaining such goals?
Some ethicists argue that physicians have the right to
refuse care that they believe is highly unlikely to
produce beneficial results; other ethicists maintain
that futility must be defined in light of the subjective
views, values, and goals of patients and their
surrogates.
MEDICAL FUTILITY




Case I
A 75-year-old woman is brought to the ER by
paramedics after suffering massive head trauma,
with extrusion of brain tissue, as a result of a
vehicular accident. She had been intubated by the
paramedics.
After careful evaluation, the ER physicians judged
that her injuries were so severe that no intervention
could retard her imminent death. When her grieving
family gather in the ER, they demand that the
woman be admitted to the ICU and be prepared for
operation by a neurosurgeon.
The physicians state that further treatment is futile.
MEDICAL FUTILITY
Case II
 Helga Wanglie was an elderly Minnesota woman
who suffered irreversible brain damage from
strokes and slipped into a chronic vegetative
state. She required mechanical ventilation.
Physicians and family agreed that she had no
hope of regaining the ability to interact with
others. However, Mrs. Wanglie's husband refused
to authorize discontinuing the ventilator, saying
that his goal (and, he asserted, hers) was that her
life should not be shortened, regardless of her
prospects for neurologic recovery. Physicians
requested court intervention to authorize
withdrawal of ventilatory support.

MEDICAL FUTILITY





Case III
A 72-year-old man with late-stage emphysema is
admitted to the ICU with fever, respiratory failure,
and hypoxemia. While he is being intubated, he has a
cardiac arrest.
He is resuscitated in the unit, but remains
unconscious after resuscitation.
He is found to have had a large anterior wall
myocardial infarction, requiring pressors to maintain
blood pressure. The laboratory calls to say that blood
culture data drawn in the ER are growing gramnegative bacteria.
Because of his multisystem organ failure and sepsis,
the physicians decide to write a DNR order, believing
that a second attempt at CPR would be futile.
MEDICAL FUTILITY
Comment
 In Case I, the physicians are speaking of futility
in the sense used in The Dying Patient, that is,
physiological futility. The issue here is not the
likelihood but the impossibility of continued life
regardless of any intervention. They are ethically
justified in refusing to pursue treatment.

MEDICAL FUTILITY

In Case II, continued ventilatory support and other
interventions can extend Mrs. Wanglie's life. These
interventions, employed for this purpose, cannot be
judged physiologically futile. However, physicians
judge that there is a vanishingly low probability of
restoring Mrs. Wanglie's health and a low probability
also that her life will be extended very long, even with
support. They also judge that Mrs. Wanglie's life, if
extended, will be of very low quality. Physicians may
recommend termination of the intervention on the
grounds of medical futility, but they lack the ethical
authority to define the benefit of continued life even
without consciousness. This is a matter for the
patient and her surrogate to decide (as the Minnesota
court determined). Some contextual features, such as
scarcity of resources, might be relevant to this case.
MEDICAL FUTILITY

In Case III, the patient's multiorgan system
failure, dependence on pressors, and sepsis make
it highly unlikely that a second resuscitation will
succeed. A DNR order should be recommended to
appropriate surrogates.
MEDICAL FUTILITY



(3) Dispute Resolution. What process should be used to resolve
disputes about futility?
Institutions should design a policy for conflict resolution.
These policies should prohibit unilateral decision making by
physicians, except in cases of physiological futility. For
judgments of futility based on low probability of successful
treatment, policy should stress the need for valid empirical
evidence, provide for consultation with outside experts and
with ethics committees, and, above all, create an atmosphere
of open negotiation or mediation rather than confrontation.
The policy should allow physicians to withdraw from cases in
which they judge continued treatment futile and should
provide for transfer of patients to other institutions willing to
accept them. Futility arguments should be moved into court
only after all other reasonable attempts to resolve the
disagreement fail. Elements of a model hospital policy on
nonbeneficial care can be found in the AMA Code of Medical
Ethics 2008, 2.037 (www.ama-assn.org).
MEDICAL FUTILITY



Despite continued debates about the concept of
futility, it is useful in medical ethics, because it
highlights the necessity to make decisions about
treatments that are of questionable benefit.
It introduces a note of realism into excessive medical
optimism by inviting physicians and families to focus
on what realistically can be done for the patient
under the circumstances and which goals, if any, can
be realized. It provides the opportunity to open an
honest discussion with patients and their families
about appropriate care.
It calls for a careful investigation of the literature
about the efficacy of proposed treatments in
particular situations.
MEDICAL FUTILITY
Physicians should never invoke futility, except in
the sense of physiologic futility, to justify
unilateral decision making or to avoid a difficult
conversation with patient or family.
 A physician's judgment that further treatment
would be futile does not justify a conclusion that
treatment should cease; instead, it signals that
discussions of the situation with patient and
family are mandatory.
 Futility should never be invoked when the real
problem is a frustration with a difficult case or a
reflection of the physician's negative evaluation
of the patient's future quality of life.

MEDICAL FUTILITY




Also, a futility claim by itself does not justify rules or
guidelines devised by third-party payers to avoid paying for
care;
Further, even when the facts of the case support a
judgment of futility, we suggest that it may be advisable to
avoid the actual word "futility" in discussions with patients
or their families.
Many persons may interpret this word as an
announcement that the physician is "giving up" on the
patient or that the patient is not worth further attention.
At this point, rather than explicitly using futility language,
clinicians should raise the question of redirecting the
efforts of clinical care to palliation and comfort, because the
burdens of more aggressive care far exceed the chances for
benefit. Ethicists sometimes refer to this reasoning as
proportionality .
MEDICAL FUTILITY
Finally, a physician has the moral right to
withdraw from a case in which he or she has
reached an honest judgment of futility, even
though continued care is demanded by others.
 Such a judgment would be based on the belief
that nothing is being done to benefit the patient,
while continued interventions actually are
harming the patient. Should a physician reach
this conclusion, proper steps to inform the family
should be taken.
 Hospital policy should support physician's
judgments in this regard.

CARDIOPULMONARY RESUSCITATION (CPR)
AND ORDERS NOT TO RESUSCITATE (DNR)
The practice of CPR provides another example in
which estimations of the probability of success
are often a crucial element of the ethical decision
to proceed with the intervention.
Cardiopulmonary resuscitation consists of a set of
techniques designed to restore circulation and
respiration in the event of acute cardiac or
cardiopulmonary arrest.
 The most common causes of cardiac arrest are (1)
cardiac arrhythmia, (2) acute respiratory
insufficiency, and (3) hypotension.
 The omission of CPR after cardiopulmonary
arrest will result in the death of the patient.

CARDIOPULMONARY RESUSCITATION (CPR)
AND ORDERS NOT TO RESUSCITATE (DNR)
Basic CPR, consisting of mouth-to-mouth
ventilation and chest compression, is taught to
lay persons for use in emergency situations.
Automatic defibrillation devices are now
available for lay use as well.
 Advanced CPR techniques include closed-chest
compression, intubation with assisted
ventilation, electroconversion of arrhythmias,
and use of cardiotonic and vasopressive drugs.
 In hospitals, advanced CPR is usually done by a
trained team who respond to an urgent call.

CARDIOPULMONARY RESUSCITATION (CPR)
AND ORDERS NOT TO RESUSCITATE (DNR)
CPR is an indicated procedure to reverse the
effects of cardiopulmonary arrest. However, it is
not indicated when a clinical judgment is made
that the procedure is unlikely to do so.
 Therefore, clinicians must recognize situations in
which low probability of success dictates a
decision to refrain from CPR.

CARDIOPULMONARY RESUSCITATION (CPR)
AND ORDERS NOT TO RESUSCITATE (DNR)





Hospitals have an explicit policy regarding CPR.
Since the 1960s, those policies have required that
CPR be a standing order, that is, CPR is to be
performed on any patient who suffers a cardiac or
respiratory arrest without needing any written order
for the procedure.
The policies require that an order be written to
authorize omission of CPR for a particular patient.
Thus, in contrast to every other hospital procedure,
clinicians may withhold CPR only when a specific
order states that it should be omitted.
This order is designated Do-Not-Resuscitate (DNR)
and is frequently called a "No Code Order."
CARDIOPULMONARY RESUSCITATION (CPR)
AND ORDERS NOT TO RESUSCITATE (DNR)


Questions have been raised about the standard policy
requiring resuscitation except when a specific order
authorizes its omission. Some commentators believe
that decisions to resuscitate should be an affirmative
order based on medical indications and patient
preferences. We agree with this position.
Under the present U. S. policies, however, the
decision to write a DNR order should be based on two
crucial considerations. The first is the judgment that
CPR is not medically indicated in the case, that is, not
likely to restore physiological function; it will be
futile, in the sense explained in Medical Futility. The
second consideration is the permission of the patient
or of the designated surrogate.
MEDICAL INDICATIONS AND
CONTRAINDICATIONS FOR CPR
A) There is conclusive evidence that the patient
is dead, such as rigor mortis, exsanguination, or
decapitation (physiological futility).
 B) No physiological benefit can be expected,
because the patient has deteriorated despite
maximal therapy for such conditions as
progressive sepsis or multisystem organ failure
(probabilistic futility).
 C) The patient has a valid DNR order

MEDICAL INDICATIONS AND
CONTRAINDICATIONS FOR CPR
Comment
 A) Cardiopulmonary resuscitation is not
indicated when
1. cardiopulmonary arrest occurs as the
anticipated end of a terminal illness,
2. and when all treatment options have failed.
Because cardiopulmonary arrest is the most
frequent cause of death for such patients, a
DNR order should be written.

MEDICAL INDICATIONS AND
CONTRAINDICATIONS FOR CPR
B) DNR orders are usually first considered when
the patient is in a terminal condition and death
appears to be imminent.
 A multicenter study of DNR orders in ICUs
showed that fewer than 2% of patients who had
DNR orders survived to be discharged from the
hospital. These patients are often imminently
dying, and thus highly unlikely to benefit from
CPR. In such cases, the DNR order allows the
patient to die without burdensome resuscitative
efforts. This achieves the medical goal of a
peaceful death.

MEDICAL INDICATIONS AND
CONTRAINDICATIONS FOR CPR





C) In the United States, the rate of DNR orders varies
from 3% to 30% among hospitalized patients and
between 5% and 20% among patients admitted to
ICUs.
Sixty-six percent to 75% of hospital deaths and 40% of
deaths in ICUs are preceded by a DNR order.
Even after adjusting for severity of illness, disparities
exist in the use of DNR orders relative to age, race,
gender, and geography.
Older patients, white patients, and women are more
likely to have DNR orders.
Some geographic areas have a DNR rate 8 to 10 times
higher than that of others.
MEDICAL INDICATIONS AND
CONTRAINDICATIONS FOR CPR






D) Studies show that the success of CPR varies with
different types of patients. Survival after CPR was more
likely in the following situations:
(1) for patients with respiratory rather than cardiac arrest;
(2) for witnessed cardiac arrests, initial ventricular
tachycardia, or fibrillation;
(3) for patients with no or few comorbid conditions;
(4) for cardiac arrest caused by readily identifiable
iatrogenic causes; and
(5) for patients who experience a short duration of arrest.
Survival is much less likely in patients with preexisting
hypotension, renal failure, sepsis, pneumonia, acute stroke,
metastatic cancer, or a homebound lifestyle. One large
study of patients older than 65 years who were resuscitated
in hospital showed a survival to discharge of 18.3%, with
survival rates lower for men, older patients, patients with
comorbidities. Survival for black patients was 23.6% lower
than for whites.
MEDICAL INDICATIONS AND
CONTRAINDICATIONS FOR CPR

One large study of patients older than 65 years
who were resuscitated in hospital showed a
survival to discharge of 18.3%, with survival
rates lower for men, older patients, patients with
comorbidities. Survival for black patients was
23.6% lower than for whites.
MEDICAL INDICATIONS AND
CONTRAINDICATIONS FOR CPR

E) Among patients who experience in-hospital
cardiac arrest and who are resuscitated, 10% to
17% survive to hospital discharge. For those
patients who survive to discharge, several studies
have shown good prognosis, with long-term
survival rates of 33% to 54%. Patients who
experience cardiac arrest outside the hospital
have a 3% to 14% chance of survival to discharge.
Among patients who survive arrest in either
setting, 11% to 14% have some neurologic
impairment at discharge and 26% have some
restriction on activities of daily living.
MEDICAL INDICATIONS AND
CONTRAINDICATIONS FOR CPR

F) Studies also indicate that even for terminally
ill patients, DNR orders are underused, as
demonstrated by the disparity between the
number of patients who had indicated a
preference for such orders in relation to those for
whom orders were actually written. Presumably,
this happens because of a lack of communication
and discussion among physicians, patients, and
their families.
MEDICAL INDICATIONS AND
CONTRAINDICATIONS FOR CPR

Physicians have an ethical responsibility to
initiate DNR discussions in the following
situations: (1) with patients who are terminally
ill or patients who have an incurable disease with
an estimated 50% survival of less than 3 years;
(2) with all patients who suffer acute, lifethreatening conditions; and (3) with all patients
who request such a discussion. When patients are
incapable of discussing DNR orders, physicians
should have such discussions with the patients'
surrogate.
MEDICAL INDICATIONS AND
CONTRAINDICATIONS FOR CPR




Patients and families often overestimate the success
of CPR. This misapprehension may be fostered by
media versions of CPR.
A study of cardiac resuscitation on television hospital
dramas showed that 67% of televised "patients"
survived, in contrast to the much lower numbers in
"real" clinical situations.
Also, many patients have little idea of the nature of
resuscitation procedures and, when informed of them,
often choose not to have resuscitation.
It is essential that patients, their families, and
physicians have accurate information on the benefits
and risks of CPR so that they can make informed
decisions about using CPR or choosing DNR status.
MEDICAL INDICATIONS AND
CONTRAINDICATIONS FOR CPR

G) DNR orders apply only to decisions about
refraining from cardiopulmonary resuscitation
and should not influence decisions about
interventions other than CPR. DNR orders are
often written when doctors, patients, and
surrogates intend to withhold or withdraw other
life-prolonging treatments. When this is the case,
distinct orders should be written specifying which
treatments other than CPR should be withheld
and under what circumstances.
MEDICAL INDICATIONS AND
CONTRAINDICATIONS FOR CPR
Case
 Mr. Care, the patient with MS, has been
admitted to the hospital in coma for treatment of
pneumonia and respiratory failure. In the past,
he has emphasized to his family and physicians
that he did not wish to be placed on permanent
mechanical ventilation. Neurologic consultation
concludes that his respiratory insufficiency is
secondary to the advancing muscular and
neurologic deterioration of MS and that
respiratory failure was accelerated by his acute
pneumonia. Should a DNR order be written?

MEDICAL INDICATIONS AND
CONTRAINDICATIONS FOR CPR




Comment
Decisions to recommend DNR orders are obviously
dependent on the clinical situation of each patient. For the
immanently dying patient, the very low probability of
success supports DNR. For other terminally ill patients,
the combination of factors, such as comorbidities and age,
must be taken into account in calculating the probability of
success.
In all cases, it is essential to recognize that CPR is not an
innocuous intervention: it can cause serious bruising,
broken bones, etc. Also, even if initially successful, another
arrest may follow, instigating another resuscitation.
Finally, intubation may initiate a life-support situation
that itself may generate an ethical problem of futility.
Therefore, the most careful evaluation of a patient's
likelihood of being successfully resuscitated and of being
discharged from the hospital is an essential component of
an ethical decision to refrain from resuscitation.
MEDICAL INDICATIONS AND
CONTRAINDICATIONS FOR CPR





Recommendations
In the case of Mr. Care, recommendations should be
made to the family that even if CPR succeeds, the
patient would survive only a short time without
permanent ventilatory support.
Based on the patient's prior wishes not to be
permanently intubated, a DNR order should be
recommended.
If the family concurs, a DNR order should be entered.
If the family disagrees, an ethics review is mandatory
because the family's decision to resuscitate is in
conflict with the patient's own previously expressed
wishes not to be on mechanical ventilation.
PATIENT CHOICE OF DNR
In addition to terminally ill and dying patients,
competent, nonterminally ill patients may
initiate discussion of DNR orders with their
physicians.
 For these patients, a DNR order is an important
component of advance care planning, allowing
them to express preferences about treatment at
the end of life.
 Many of these patients are in the earlier phases
of serious diseases, such as metastatic cancer,
AIDS, or ALS.

PATIENT CHOICE OF DNR
They are prepared to forgo resuscitation attempts
because they are concerned that even if they are
"successfully" resuscitated, they may experience
anoxic brain damage or some other functional
impairment or go on to live through a painful
terminal phase of their illness.
 Physicians should carefully discuss these
requests with the patient and honor them. While
very few ICU patients with DNR orders survive
to hospital discharge, outcomes for nonterminal,
seriously ill patients are much better.
 Several published studies have shown survival to
discharge to be as high as 50% to 70%.

DNR ORDERS WITHOUT OR CONTRARY TO
CONSENT
Ordinarily, the consent of the patient or the
patient's surrogate is required to write DNR
orders. Three situations raise questions about
this general rule.
 (a) A patient may be unable to give consent and
no surrogate can be identified.
 (b) Medical indications may not support the
utility of CPR, but surrogates insist that it be
done.
 (c) In an emergency crisis, when survival is
highly unlikely.

DNR ORDERS WITHOUT OR CONTRARY TO
CONSENT



Medical ethicists are divided on the question whether
it is ever ethically acceptable for a physician to make a
unilateral decision, that is, a decision not to
resuscitate without the consent of the patient or the
patient's surrogate, perhaps even in the face of
objections from the patient or surrogate.
Those in favor of unilateral decisions argue that no
medical procedure that is not indicated, that is,
unlikely to effect a positive change in the patient's
condition, should be performed.
Further, they argue that CPR performed in these
situations can cause great distress to the patient,
adding to the burdens of immanent death. Finally,
they note that even a successful resuscitation in the
crisis would likely lead to another crisis and another
resuscitation attempt, ad infinitum.
DNR ORDERS WITHOUT OR CONTRARY TO
CONSENT
Those who oppose unilateral decisions maintain
that the patient should always have the right to
refuse or choose CPR, because a decision about
the goals of treatment and the acceptable
probability of attaining those goals is a value
judgment only the patient can make.
 Depending on the patient's goals, even the
remote chance of successful resuscitation may be
of value to the patient.
 These critics also assert that the concept of
futility is too vague to be consistently applied.
Critics of unilateral DNR also warn that such
decisions are open to bias against patients at risk
of discrimination.

DNR ORDERS WITHOUT OR CONTRARY TO
CONSENT
Comment
 If the physician has concluded that CPR has no
prospect of resuscitating the patient, the
physician may recommend that CPR be withheld.
 If the patient is unable to consent to this
recommendation, and no surrogate is available, a
DNR order may be written on the basis of futility.

DNR ORDERS WITHOUT OR CONTRARY TO
CONSENT




If patient or surrogates refuse the recommendation,
the physician should seek a second medical opinion
about the futility or utility of resuscitation. The "two
doctor rule" is frequently misunderstood.
The opinion of a second physician is not equivalent to
permission or consent to DNR; it is simply a
confirmation of the first clinical opinion that
resuscitation would be unlikely to benefit the patient.
Serious attempts to reconcile differences of opinion
should be undertaken. An ethics consultation should
be sought.
If no agreement can be reached, the hospital policy on
nonbeneficial care should be invoked.
DNR ORDERS WITHOUT OR CONTRARY TO
CONSENT
A physician may, however, refrain from
resuscitation when an arrest occurs, or is likely
to occur, in a critical situation in which it is
apparent that the patient's survival, under any
circumstances, is highly unlikely.
 Therefore, patients arriving in the ER with
extreme traumatic injuries, or after being found
down for an extended period of time, need not be
resuscitated.

DOCUMENTATION OF DNR ORDERS

Code status should be clear to all who have
responsibility for the patient, particularly nurses
and house officers. Attending physicians should
clearly write and sign the DNR order in the
patient's chart. The progress notes should include
the medical facts and opinion underlying the
order and a summary of the discussion with the
patient, consultants, staff, and family. Some clear
sign of the DNR status should be affixed to the
chart, such as a green dot. The status of the order
should be changed if the condition of the patient
warrants it.
DOCUMENTATION OF DNR ORDERS
Everyone involved with the care of the patient
should be informed of the DNR order and its
rationale.
 Because studies have shown that DNR means
different things to different practitioners, the
physician writing the order must be careful to
document the specific terms of the order.
 The writing of a DNR order should have no direct
bearing on any treatment other than CPR.
 If a DNR order has not been written, the patient
is presumed to be "full code." Code status should
be reevaluated at each hospital admission.

DNR PORTABILITY





Patients for whom DNR orders have been written in
the hospital may be discharged with the expectation
that they will die soon.
Often, patients want to die in their own homes rather
than in the hospital.
Family members sometimes summon emergency
services if these patients suffer a crisis at home.
Traditionally, emergency medical service providers,
because of the time constraints inherent in emergency
services, were not responsible for determining
whether a patient had an advance directive.
They attempted to resuscitate all patients regardless
of the patients' preferences.
DNR PORTABILITY





In recent years, a method of protecting an individual's
preference not to be resuscitated has been devised.
This is called a "portable" DNR. These are orders issued by
the patient's discharging physician, stated in a standard
form, and indicated on bracelets, necklaces, or wallet cards.
When the patient has this order, emergency technicians
are authorized to refrain from CPR, although all other
necessary treatments can still be provided.
Almost every state now has laws or regulations mandating
that EMS providers comply with out-of-hospital DNRs.
Once the emergency care provider has verified that the
order appears valid and that the patient is the person who
has executed it, the provider cannot commence CPR except
in certain circumstances, such as when the patient
renounces the document.
POLST ORDERS (PHYSICIANS ORDERS
FOR LIFE-SUSTAINING TREATMENT)
The POLST paradigm is a physician's order form
that contains a summary of a patient's choices
about the nature and extent of life-sustaining
procedures that they wish to have done or
omitted.
 The form contains four sections
 A: Cardiopulmonary Resuscitation;
 B: Medical Interventions, that is, comfort
measures only, limited interventions or full
treatment;
 C: artificially administered nutrition; and
 D: summary of medical condition.

POLST ORDERS (PHYSICIANS ORDERS
FOR LIFE-SUSTAINING TREATMENT)
POLST is a physician order and is signed by the
physician. But unlike most physician orders, it is
also signed by the patient or the surrogate. It
should be a part of the patient's hospital record.
 The primary purpose of POLST is to record all
the patient's wishes in a single document and
ensure that these wishes follow the patient
across different health care settings, for example,
from the acute care hospital to a skilled nursing
facility.

DNR ORDERS IN THE OPERATING ROOM




Patients may suffer a cardiac arrest in the course of a
surgical intervention.
In such cases, anesthesiologists immediately initiate
resuscitation.
Occasionally, patients for whom a DNR order has
been written, such as patients with terminal cancer,
may require a palliative surgical procedure, such as
emergency relief of a bowel obstruction to relieve pain
or the elective insertion of a gastrostomy tube or a
central venous catheter.
The question is whether the DNR order should be
suspended automatically during anesthesia or
surgery so that resuscitation would be performed if
the patient experienced a perioperative cardiac
arrest.
DNR ORDERS IN THE OPERATING ROOM





The arguments favoring automatic suspension of
DNR are as follows:
(1) anesthesia and surgery place patients at risk for
cardiac and hemodynamic instability;
(2) most arrests in the operating room are reversible,
because skilled personnel and equipment are at hand;
(3) in consenting to surgery, the patient can be
assumed to give implied consent for resuscitation;
(4) surgeons and anesthesiologists should not be
prevented from treating potentially reversible
situations, especially because they do not wish deaths
of terminally ill patients to be considered surgical
deaths when standard resuscitative techniques have
been prohibited
MEDICAL ERROR

Physicians not only work under uncertainty, but
they also make mistakes. An Institute of
Medicine report (1999) on medical error
estimated that between 44,000 and 98,000
Americans die each year as a result of medical
errors—more than the number who die from
vehicular accidents or from breast cancer or
AIDS.
MEDICAL ERROR




Error was defined as the failure of a planned action to
be completed as intended, or as the use of a wrong
plan to achieve an aim.
The report highlighted the personal and financial
costs of error and noted that some errors were due to
incompetence or errors of judgment by competent
physicians.
Other errors were caused by system failures that
often went unrecognized and uncorrected.
Following the IOM report, serious efforts have been
launched to reduce medical error by increased
reporting and analysis of error, by focusing on
hospital safety through use of computerized orders
and medical records, by establishing patient safety
indicators, and by attempting to alleviate the effects
of fatigue for house staff and nurses.
MEDICAL ERROR
Our definition of medical error is an
unintentional lapse in a process usually done
efficiently and effectively due to
 (1) inadequate information and/or
 (2) mistaken judgment and/or
 (3) defective maneuvers that may or may not be
negligent, and may or may not cause harm.

MEDICAL ERROR
Every instance of presumptive error should be
analyzed in terms of these elements. It is most
important to determine whether or not the error
was due to negligence, that is, a performance
that peers in a specialty would judge as a
departure from accepted standards of practice.
 Medical error raises ethical problems related to
truth telling.
 Systemic error describes clinical systems or
record-keeping systems that, due to unclarity or
inadequacy, lead clinicians to make mistakes.

MEDICAL ERROR
For example, the abbreviation "u" to designate
"units of insulin" can easily be read as "0," such
that 10 units is read as 100 units.
 Systematic error is an issue of organizational
ethics: "u" is now generally a disapproved symbol
in prescription writing.

DETERMINATION OF DEATH





The obligation to provide medical intervention ceases
when the patient is declared dead. Declaring death is
one of the legal duties of physicians.
Traditionally, the moment of death was considered to
be the time when a person ceased, and did not
resume, communication, movement, and breathing.
The body soon becomes cold and rigid, and
putrefaction sets in.
Physicians customarily determined death by noting
the absence of respiration and pulse and the fixation
of pupils.
Thus, the common definition of death, accepted in
medicine and in the law, was "irreversible cessation of
circulation and respiration." This is known as the
"cardiorespiratory criterion" of death.
DETERMINATION OF DEATH
This criterion presupposes loss of the integrating
function of the brainstem.
 When this function ceases, spontaneous
breathing stops, followed by a disintegration of
all vital organ systems.
 The unoxygenated brain rapidly loses all
cognitive and physiologic regulatory functions;
the unoxygenated heart ceases to beat. In the
1960s, it became possible to maintain respiratory
functions by the use of a mechanical ventilator,
which supports oxygen perfusion even in the
absence of brainstem function.

DETERMINATION OF DEATH




An individual who has sustained either
(1) irreversible cessation of circulatory and
respiratory function, or
(2) irreversible cessation of all functions of the entire
brain, including the brain stem, is dead. A
determination of death must be made in accordance
with accepted medical standards.
(President's Commission on Ethical Problems in
Medicine and Biomedical and Behavioral Research.
Defining Death: A Report on the Medical, Legal, and
Ethical Issues in Definition of Death. Washington,
DC: Government Printing Office; 1981.
http://bioethics.georgetown.edu/pcbe/reports/past_com
missions/defining_death.pdf. )
DETERMINATION OF DEATH

1.
2.
3.
4.
The accepted medical standards for clinical diagnosis of
death by brain criteria are as follows:
after ruling out confounding conditions such as drug
intoxication and severe hypothermia,
it should be demonstrated that there are no voluntary or
involuntary movements except spinal reflexes and no
brainstem reflexes; apnea is demonstrated in the
presence of elevated arterial CO2 when mechanical
ventilation is temporarily halted, pupils are dilated, fixed
at midposition, and there is no reaction to aural irrigation
nor gag reflex.
Brain blood-flow studies are confirmatory but rarely
necessary.
Electroencephalography, which diagnoses only the
absence of cortical function, is not sufficient to establish
total brain death and may be omitted in the presence of
the above clinical signs.
DETERMINATION OF DEATH






No medical goals are attainable for a person who is dead by
either cardiorespiratory criteria or brain criteria.
No medical interventions are indicated, and all current
interventions should be terminated.
The physician has the authority to declare the patient
dead.
There is no legal or ethical requirement to seek permission
from the family to declare a patient dead or to discontinue
medical interventions.
The family should be sensitively informed that their
relative has died.
Contextual features of a particular case might suggest a
continuation of supportive technology, for example,
sensitivity to needs of family and friends of the patient,
salvage of a viable fetus from a brain-dead pregnant
woman, or retrieval of organs for transplant .
DETERMINATION OF DEATH
Physicians must distinguish the ethical and legal
implications of death by brain criteria from the
implications of the vegetative state. Lay persons
(and some physicians and nurses) use the term
brain death when they are referring to a
vegetative state.
 This is wrong.
 Clinicians should use the term death by brain
criteria when determining death.

SUMMARY

Question Five—in Sum, How Can This Patient
Be Benefited by Medical and Nursing Care, and
How Can Harm Be Avoided?
SUMMARY
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Question Five—in Sum, How Can This Patient Be
Benefited by Medical and Nursing Care, and How
Can Harm Be Avoided?
This final question for Medical Indications moves
beyond the gathering and sorting of factual
information about the patient's condition and
treatment. It requires the clinician to assess how
these facts relate to the principles of beneficence and
nonmaleficence, and how that assessment can lead to
a recommendation about appropriate action. When
the clinical facts reveal that a condition is probably
treatable, and when benefit–risk reasoning inclines
toward intervention, the principles of beneficence and
nonmaleficence urge a prudent medical intervention.
QUESTION FIVE—IN SUM, HOW CAN THIS PATIENT
BE BENEFITED BY MEDICAL AND NURSING CARE,
AND HOW CAN HARM BE AVOIDED?
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When, as our discussion of futility shows, the facts
favor the opinion that the condition is not amenable
to treatment, or when the harm that might occur as a
consequence of treatment is significant, the obligation
to intervene is diminished, or extinguished.
The principle of nonmaleficence then becomes
stronger, directing the alleviation of burdens on the
patient.
Certain benefits of nursing care and palliative
treatments remain possible.
Finally, as our discussion of death shows, neither
benefit nor harm is possible and no intervention
whatsoever is indicated.
QUESTION FIVE—IN SUM, HOW CAN THIS PATIENT
BE BENEFITED BY MEDICAL AND NURSING CARE,
AND HOW CAN HARM BE AVOIDED?
It must be emphasized that this chapter has
dealt with benefit in its objective medical sense,
namely, the physical or psychological
contributions that will restore a state of health.
 The clinician's judgments about these objective
benefits must now be fashioned into a
recommendation offered to the patient for his or
her personal consideration and acceptance (or
refusal). This is the matter for Part, Patient
Preferences
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THANK YOU FOR YOUR
UNDERSTANDING!
Jaromir.matejek@lf3.cuni.cz